Remarks on Global Health by Members of USAID's Bureau for Global Health Leadership Team

(Chris Thomas): Thank you and thank you all for joining the call today, with members of USAID's Bureau for Global Health leadership team, who will speak on the five transformational goals that USAID administrator, Rajiv Shah, outlined this morning at the David E. Barmes lecture at NIH. I hope you had a chance to attend in person or watch the lecture online. You can access archived video from the lecture on USAID.gov and we hope that this will be the first in a series of phone calls with you on topics in global health.

I will introduce our speakers in the order that they will speak. First is Susan K. Brems, Senior Deputy Assistant Administrator, Global Health; she'll provide opening remarks. Then Amy Batson, Deputy Assistant Administrator for Global Health will talk about vaccines and immunizations. Admiral Ziemer, U.S. Malaria Coordinator, then Scott Radloff, Director of Office of Family Planning, Reproductive Health, Robert Clay, Director Office of HIV/AIDS, and then Christy Hanson, Chief of the Infectious Disease Division, who will speak about TB.

Ground rules; this is on the record, so things said today can be attributed to the speaker. USAID participants will provide remarks and then afterwards will take questions. And we are talking today about the transformational goals, not the FY 2011 or FY 2012 budget. Thank you very much; (now) turn to Susan.

Susan K. Brems: Hi, good afternoon. Today at midday, USAID Administrator, Rajiv Shah, gave the David E. Barmes Global Health Lecture at the National Institutes of Health. The title of his presentation was The Role of Science in Global Health Development. This annual lecture is cosponsored by the Fogarty International Center and the National Institute of Dental and Craniofacial Research.

Recounting the successes that have been achieved in recent decades in global health, Dr. Shah outlined the challenges that currently exist and set out a roadmap for USAID and the wider health community to take advantage of the window of opportunity in front of us to accomplish a new wave of successes that can dramatically improve health around the world, particularly for children under age five and women.

He explained that this window of opportunity exists because of the convergence of three factors. One is the efficiencies that can be gained under President Obama's Global Health Initiative. A second are the Scientific and Technological breakthroughs that we currently have at our disposal, as well as ones that are on the horizon. In this, he stressed the salience of a strong partnership between NIH and USAID, with NIH playing the lead role in scientific discovery. And third is USAID's expertise in rolling out implementation of scientific breakthroughs and scaling them up so their potential can be realized.

USAID has decades of experience in community-based work that takes healthcare out of fixed facilities and into the community. In this, the role of community health workers is paramount, as Dr. Shah stressed. He challenged USAID to build on this expertise to be an even more dynamic and forceful leader in taking health literacy and healthcare to the community. Dr. Shah closed his presentation with a powerful illustration. He asserted that a world class vaccine does not require a world class facility to be effective.

He said our battleground to improve health is outside the formal system and in the community. We must concentrate on extending the reach of health interventions. Throughout his presentation, Dr. Shah focused on five areas of health, where technological breakthroughs can be in the vanguard of effecting these transformational changes. And each of our next speakers, as (Chris Thomas) said, will focus on one group of these, beginning with Amy Batson, who will talk about the power of vaccines.

Amy Batson: (The) vaccines are a perfect example of the transformative breakthroughs that we think are going to be the key to our achieving major health gains over the next 5 to 10 years. I think it's - in - it's captured by the issue that I can bring my daughter to our pediatrician in Bethesda and she gets the same kind of protection that a child in an African rural community would get by visiting their health worker.

We don't need to build hospitals. We don't need to train tens of thousands of doctors. We just need to introduce these vaccines into the health system that can reach beyond the fixed facilities. And by introducing - by having the vaccines we've had in the last decade, we've already saved 5 million - over 5 million children's lives. And by introducing the next wave of vaccines, the pneumococcal conjugate, rotavirus, meningococcal A, and scaling up the Pentavalent vaccine, we can save another 4 million lives over the next five years, because we can reach every child.

What we need to do is accelerate their introduction, working with pivotal partners like GAVI, the Global Alliance for Vaccine and Immunization, where every dollar that the U.S. government invests is matched by other partners and other donors to cost-effectively and in coordination with others, ensure that vaccines are getting out to all children. We also need to be investing in the cold chain and the logistics systems to ensure we have a strong mechanism to get the vaccines, support them and keep them effective and - keep them effective. By doing this, we're going to pave the way for the future vaccines; malaria, TB and HIV/AIDS, which are ultimately critical to breaking the backs of these diseases.

However, as Dr. Shah noted, despite the fact that we have mechanisms like GAVI to procure the lowest tiered price for vaccines, despite the fact that we have delivery systems which can reach all children, despite the life-saving potential of vaccines, we still have trouble ensuring the resources to invest in making them available. As a result, Dr. Shah directed us to invest more in vaccines. We in USAID will be ramping up our technical capacity to support them, as well as our financial support. And I know as a mother how important vaccines are and I know that they're equally important to mothers around the world and that's why we're putting such a - big) attention on them.

Timothy Ziemer: From a malaria perspective, Dr. Shah made two points. He acknowledged the investment that the United States government has already made and the remarkable trends that we're seeing sub-Sahara Africa particularly, with our partners. The real challenge was to learn from those and to build on those successes. He painted the vision of moving - removing malaria as a public health threat in order to achieve a healthier world and that underlined his entire malaria focus.

The transformational goal for malaria was a specific target of 700,000 lives saved by 2016. Now we didn't pull that figure out of the blue. It aligns with the World Health Organization's last annual report, which reported the death - (as the) approximate deaths of 781,000. That was (deaths) down from 1 million a couple years ago. This target aligns with the Millennium Development goals, WHO goals and the Roll Back Malaria goals and it's linked, as I said, to the Millennium Development goals four, five and six.

Is this attainable with our current effective interventions? Raj mentioned them in his address. The truth is, and he acknowledged this, is that USAID can't do this alone, nor can we eliminate malaria as a public health threat without strong collaboration with the research community obtaining and getting a vaccine, developing new insecticides and finding an alternative to artemisinin as the basis for our combination therapies. We hope and pray for the arrival of that vaccine quickly. What you heard Dr. Shah say was bridging the realities of today with his vision for the future and we do that by embracing innovation, research and science as part of the global health initiative.

At the same time though, he's committed, along with us, to keeping our sleeves rolled up and improving our development outcomes in health in the countries where we're working through the GHI, focusing in on a number of principals. And I'm going to reiterate them, because malaria touches all of them; maternal health, integration of resources and services, particularly in the prenatal clinics, laboratories, logistic hubs, working from a common national malaria control plan, that's country ownership and building capacity and health system strengthening at every level.

And he particularly focused in on the community health workers and improved case management and diagnosis of (favors) through that component of health system strengthening. And then, lastly and importantly, a robust M&E component and that's to show the impact of the dollars that we've invested towards achieving the lives saved; all of that towards his vision of achieving a healthier community in the places where USAID works.

Scott Radloff: This is Scott Radloff and I'm going to talk a bit about family planning. USAID has been a leader in family planning for 40 years and we have successes in every part of the developing world. One of the points that the - Administrator Shah said in his speech today is that our experience with GHI has made clear that our largest opportunities to improve human health do not lie in optimizing services for the 20 percent of people (in) developing world currently reached by health systems. They lie in extending our reach to the 80 percent who lack access to health facilities.

And that rings true for family planning and for maternal-child health. For family planning, the poorest countries of the world often have 25 to 35 percent of women who have an unmet need for family planning. That is they either want no more children or want to space their next birth two or more years and aren't using a method of family planning, so they're exposed to unintended pregnancy. There are 215 million women in developing countries who have an unmet need for family planning. A goal of the Global Health Initiative is reducing unintended pregnancy by 54 million over the years - the six years of the Global Health Initiative.

In these - the poorest countries of the world, we find that the highest levels of unmet need are among the poor segments of the population, among the rural, among the less educated, so the key is to get the services closer to the women and families in the communities. And where we've seen successes, in Africa and South Asia, where the focus of our program is, has been due to our ability to reach communities with information and services.

We have 24 priority countries for family planning. We have 24 priority countries for maternal-child health. With one exception, those countries are the same. The same countries that have a high need for maternal-child health services are the same countries that have high need for family planning, so we're aligning our programs, we're integrating our programs and we're taking a community-focused approach.

We're also integrating our programs with HIV as a priority for us. And as was mentioned before, a key also in our programs and other programs is supply chain; strengthening supply chain. So we need to reach the communities and we need to have a supply chain that can guarantee continuous supply of commodities, so that's a focus of our programs as well.

Male: Did you already mention the …

Robert Clay: So this is Robert Clay and on HIV/AIDS, Ambassador Shah - or Administrator Shah started off talking about the emergency that we have in HIV/AIDS. And just to make this a little personal, 10 years ago I was in Zambia, where we had 20 percent prevalence of HIV/AIDS and the mortality was probably at its peak at the time. We had - everyone in Zambia was affected by this disease and the world basically was not seized with this issue. And it really was very frustrating, being out in the field, working, seeing the devastating impact of HIV/AIDS and not seeing the large response that we felt was necessary.

Well that changed radically over the next decade, when we saw PEPFAR launched, we had the MAP program from the World Bank, the Global Fund, as well as UNAIDS, and as the - as Administrator Shah pointed out, this - all this huge international mobilization showed that we could actually bring additional resources in large amounts to a program and have very concrete results. And as Dr. Shah also mentioned, it brought optimism that this war could be won.

So in the emergency phase, we did treat over 5 million people and we were able to demonstrate reaching people with care, but we can't treat ourselves out of this epidemic and I think that that was a - that's really the key message that Dr. Shah made in this speech. And in order to go forward, he mentioned a much great - much greater focus on prevention, specifically on combination prevention, which includes by biomedical, behavioral and structural interventions as we move forward.

The speech laid out that we needed to do more evidence-based programming, looking at our target audience and making sure that we're addressing our programs to their needs. We need to make sure that our programs are going to scale. We have a lot of small programs, but they're not actually having the size of impact that we need in order to turn the tide in this epidemic. And he also stressed the use of existing and new technologies. And he mentioned five technologies that, when brought to bear in this field, would have a tremendous impact.

The first of these has actually been around for almost a decade and that is mother-to-child transmission, providing ARVs to the mother so that the child would not be infected. This technology has been developed in early 2000 and we've been a little disappointed that it hasn't taken off more rapidly. And part of this is health systems, but also it has a big cultural and societal barrier that we need to face in the future.

The second is male circumcision, which has been demonstrated to show 80 - 60 percent reduction and we've had some recent activities of scaling this up, both in Kenya and Tanzania and currently we're working in Swaziland and this can have a major impact, but a new - a relatively new intervention that we're now scaling up through our program.

A third technology was microbicides, which is actually - we have just the proof of concept through the CAPRISA trial in South Africa and we're now looking at how to - how to have a confirmatory. We're actually carrying out a confirmatory trial and then looking at steps that we can accelerate the introduction of this technology into our program, so that we don't have a lag between a new intervention and the actual impact in the field.

There's also the recent findings in terms of prophylactics for men who have sex with men and 44 percent reduction on that side. We're - USAID is also carrying out a prophylactic study looking at women and we hope to have that result soon. And then finally Dr. Shah mentioned the promise of having a vaccine, which this past year got a tremendous boost from the evidence from the Thailand trial and we're hoping that over the long run that this will be a new technology that will be able to help turn the tide.

Christy Hanson: This is Christy Hanson. I'll speak a little bit about tuberculosis. Administrator Shah laid out today the real need to see new technologies for tuberculosis to enable us to turn the tide on the tuberculosis epidemic and the really profound need to be able to roll out the tools as they become available.

Within USAID, we're currently supporting TB control activities through national TB programs in 40 countries around the world. Some of the flagship areas of work for USAID have been to ensure the engagement of the private sector in both the diagnosis of TB cases and the treatment of TB cases and this is - the private sector is very important service provider in many of the countries in which we work. Another flagship area is the involvement of communities, again, in detecting and in helping to manage the cure - the treatment and ensure cure of TB patients. We feel that both of these platforms are going to be critical if we are really going to accelerate the uptake of new technologies.

Within USAID, we are investing in some late stage research, where we feel we have a comparative advantage to contribute to the field. Some of the exciting developments, as described by Administrator Shah, are our investments in shorter treatment through new drug development. We're currently supporting four new drugs that have reached late stage and promise to deliver shorter treatment regimens for patients who currently face six months of treatment before they can be cured of TB.

We're also evaluating a shortened regimen for the management of multidrug-resistant TB. But I think most importantly today is, as we have seen new diagnostic technologies become available, the most recent to be adopted by WHO is a - is a rapid diagnostic that enables the detection of TB and also the identification of resistance to rifampicin. This is a major development in the world of TB and we are going to support countries to consider how it might be best used in their diagnostic algorithms.

USAID is very interested in the investments in health systems and so when it comes to new technologies and their uptake, we will have a very keen focus going forward on ensuring that any new technology is well positioned within the health system, within the laboratory system, the laboratory network to ensure that it is most efficiently and effectively used in combination with other tools that already exist. I think, as Ambassador Ziemer mentioned, we are very much looking to the future with the new technologies and the new tools, but we also recognize that we have to roll up our sleeves today with the technologies that we have, embracing everything that's new that comes along, but making sure that we pull it into context at the country level and try to strengthen systems as we move forward.

With this combination of rolling up our sleeves and embracing new technologies and trying to further the development of technologies, we do hope that we can achieve the goal stated today in the speech of reaching and successfully curing over 2 million, almost 2-1/2 million new TB patients by 2016. Thank you.

(Chris Thomas): OK. Now we're going to do the questions and answers. Please, when the questions queue up, only ask one and we'll try to - so we can go through; there's a lot of people on the call.

Operator: At this time, I would like to remind everyone, in order to ask a question, press star then the number 1 on your telephone keypad. We'll pause for just a moment to compile the Q&A roster.

Your first question comes from the line of (Julie Terkowitz). Your line is open.

(Julie Terkowitz): Hi, yes. My question is actually for Robert Clay. One of the things that was mentioned was an increased effort or increased focus on prevention and you had said something to the effect of we can't treat ourselves out of this epidemic. I was wondering if you could speak to efforts to fight an increasing number of - or efforts to fight, or perhaps not fight an increasing number of HIV-specific laws that specifically criminalize HIV in Africa.

Robert Clay. Thank you very much. That's a very important question, because as we know, stigmatization - stigma and discrimination are really a driver of this epidemic and we need to make sure that we don't have those types of laws on the books. We've seen this probably most prominent in Uganda, but we're also seeing some resurgence in other areas, where we're having some parts of society suggesting that we need to have criminalization of people who engage in risky behavior.

This is really something that the U.S. government is dealing with at a very high level. We refer to this as part of our health diplomacy agenda and, as you know, with the PEPFAR program, the State Department and the ambassadors are heavily involved in our response - our response to these - to issues such as this nature and they have been in dialog with governments and have been expressing the perspective (of) the United States government in terms of how these types of laws can actually worsen the epidemic and drive the epidemic underground and the consequences for their government.

So those dialogs have been going on. The other thing that we've been working with is through our partner organizations, such as the Global Fund, UNAIDS, WHO to make sure that we're all basically having the same discussions and presenting the same points and also talking with one another of how best to handle our dialog on this very important issue. I would also mention that some of the heads of these organizations are having some one-on-one conversations with both parliamentarians and heads of government and we're hoping that this is going to have an impact.

(Chris Thomas): And I'd like to ask all participants to identify their organization. Thank you.

Operator: Your next question comes from the line of (Tenia Di Elnita) from IPS News. Your line is open.

(Tenia Di Elnita): Thank you. My question is actually for Scott Radloff and I was just wondering if you (have any discussions on the practice the) (inaudible) (Obama's) GHI is (a pro nice organizers) and whether that has any bearing on family planning and maternal-child health within the U.S.

(Amy Batson): (Hello) (Amy Batson). So (Milla Thom) was brought it, because she has excellent experience at management and change management in particular. And so she has been brought in by the Secretary of State and is reporting to the three leading implementation agencies; Administrator Shah, Dr. Frieden and Ambassador Goosby and then the Secretary on the implementation of the QDDR, and so the day-to-day of GHI, as well as the transition of GHI to USAID upon meeting certain conditions. And so that's why she was - that's why she was brought in and we're very excited to have her.

Female: Thank you.

Operator: Your next question comes from the line of (Mandy Sletzger) from Results Educational. Your line is open.

(Mandy Sletzger): Hi. This question is for Scott and Chris. I know that you spoke a lot about integrating family planning and the challenge to have health programs with HIV services and I was wondering if you're looking at doing the same for tuberculosis services, as we're finding with the HIV rates going up in sub-Saharan Africa for women that the tuberculosis rates and TB (generally) co-infections also going up and if you have plans to integrate TB screening into ANC services.

(Scott Radloff): Christy, would you mind taking that first?

Christy Hanson: Sure, I'd be - I'd be happy to. Thank you for this question. This is an area where USAID works very closely with OGAC and the PEPFAR funding. It actually is a matter - we follow very closely the WHO guidance and the global community guidance that we have 100 percent targets, in terms of we hope that all TB patients receive a test for HIV and if - are - if they are HIV positive that they be eligible for antiretroviral therapy. And similarly, we expect that 100 percent of HIV positive individuals will receive a TB screening periodically, as they - as they are cared for.

This is global policy. This is our policy and we're striving to reach this through a combination of both the USAID programming at country level and the OGAC programming. OGAC does have a strong focus on TB/HIV collaborative activities and a working group that supports that programming, so this is indeed an intense focus for us across the USG.

Male: Thank you.

Operator: Your next question comes from the line of Meredith Mazzotta from Science Speaks. Your line is open.

Meredith Mazzotta: Hi. Shah spoke at length today about the power of vaccines, but he failed to mention the need for a TB vaccine. Is this a priority for USAID? If not, why and has USAID identified another source for the funding for later stage TB vaccine trials? And if so, does USAID plan to invest in late stage trials for a TB vaccine?

Christy Hanson: Yes, he actually - we do think TB vaccine is an extremely important vaccine of the future and he did in fact mention it with malaria and HIV, that the three of these are areas where vaccines would allow us to kind of break the backs of the diseases.

So we do consider it a priority. It still is in an earlier stage of research and we look strongly to partners like NIH, the National Institutes of Health to be - to be leading and driving some of that discovery, but we see USAID playing an important role in helping pave the way for this vaccine and then very rapidly introducing and scaling it up, as soon as we have an effective vaccine that can meet the needs of the countries.

Operator: Your next question comes from the line of Heather Ignatius from TB Alliance. Your line is open.

Heather Ignatius: Thank you. First I just wanted to USAID staff and Dr. Shah for outlining this visionary approach to global health. I was interested in hearing more about the proposed center of excellence to accelerate product development in field introduction that Dr. Shah announced earlier today. And specifically I was wondering how this initiative will connect with the other product development projects currently supported within the various disease areas. Thank you.

(Christy Hanson): Thank you. So we're very excited about this idea of a concept - of a center of excellence. The goal is to really help capture the expertise that exists across a number of product development areas that we have ongoing right now at USAID and then take it a step further, so that we are - we are capitalizing on this strength; to accelerate the introduction, to scale up all of the sort of end stage steps required to ensure that great discoveries actually reach the people that need them the most.

So this would be bringing in and capitalizing on expertise on things like the forecasting, the - working on the markets and the production capacity, the financing, the communications necessary, and ensuring that we're helping provide those target product profiles so that the discoveries themselves are shaped towards what really needs to be the characteristics of a product, so that it can - it can be used in country.

Operator: There are no further questions at this time. I turn the call back over to the presenters.

(Chris Thomas): If there are no other questions, thank you again for participating on the call and we look forward to having future calls with you. Thank you.

Operator: This concludes today's conference call. You may now disconnect.